HOW DOCTORS THINK by Jerome Groopman, MD, Houghton Mifflin Company, Boston - New York, © 2007 by Jerome Groopman, ISBN-10: 0-618-61003-0, 307 pp, $26 (US) $34.95 (CAN). Tantor Audio Book,, © 2007 Tantor Media, © 2007 by Jerome Groopman. Nine CDs – 10.5 hours read by Michael Prichard, $34.99 (US) $38.99 (CAN)

Reviewed by Del Meyer, MD

Doctor Jerome Groopman, who spoke at the International Meeting of the American Thoracic Society on May 22, 2007, has written his fourth book. This book is about what goes on in a doctor’s mind as he or she treats a patient and how intricate the mechanism can be in getting the patient to understand and follow the logic. It also gives insight into the holes in that logic. On average, a physician will interrupt a patient describing her symptoms within eighteen seconds. In that short time, many doctors decide on the likely diagnosis and best treatment. Often, decisions made this way are correct, but at crucial moments they can also be wrong – with catastrophic consequences. And sequential consultants can continue to be wrong. Everyone reads the previous consultants reports and generally make the same diagnosis, and if wrong, the same mistake.

The first example in Groopman’s book is the story of Anne Dodge, a patient with Irritable Bowel Syndrome (IBS), who had seen around 30 physicians over 15 years. At age 20, she found that food did not agree with her. After a meal, she would feel as if a hand were gripping her stomach and twisting it. The nausea was so intense that occasionally she vomited. Her family doctor examined her and found nothing wrong. He gave her antacids. But the symptoms continued. Anne lost her appetite and had to force herself to eat; then she’d feel sick and quietly retreat to the bathroom to regurgitate. Her family doctor suspected what was wrong, but to be sure he referred her to a psychiatrist and the diagnosis was made: anorexia nervosa with bulimia, a disorder marked by vomiting and an aversion to food. If this wasn’t corrected, she could starve to death.

Anne had seen many internists over the years and had settled on her current one, a woman whose practice was devoted to patients with eating disorders. She had also been evaluated by numerous specialists: endocrinologists, orthopedists, hematologists, infectious disease doctors, and, of course, psychologists and psychiatrists. She had been on a number of antidepressants and had undergone weekly talk therapy. Nutritionists closely monitored her daily caloric intake.

Anne’s health continued to deteriorate. Her blood count and platelets dropped to perilous levels. Bone marrow biopsy found very few cells left to make blood. This was attributed to nutritional deficiency. Anne also had severe osteoporosis equal to that of a woman in her 80s who lacked calcium and vitamin D. Her immune system was failing as she developed a series of infections including meningitis. She was hospitalized four times in 2004 in a mental health facility so she could try to gain weight under supervision.

Her personal internist who specialized in eating disorders told Anne she must consume three thousand calories a day, mostly in easily digested carbohydrates like cereals and pasta. But the more that Anne ate, the worse she felt. Her nausea and vomiting now progressed to severe intestinal cramps and diarrhea. He internist said she had developed irritable bowel syndrome, a disorder associated with psychological stress. By the end of 2004, Anne’s weight had dropped to 82 pounds. Although she was forcing down close to three thousand calories, her internist and her psychiatrist took the steady loss of weight as a sure sign that Anne was not telling the truth.

Anne was then seen by Dr. Myron Falchuk, another gastroenterologist. She was doing this only to please a friend who was very insistent. Dr. Falchuk had already received Anne’s records and also a personal call from her internist. The internist told Dr. Falchuk that Anne’s IBS was another manifestation of her deteriorating mental health. Falchuk’s implicit understanding was that he was expected to examine Anne’s abdomen and would recommend that she should be treated just as her internist had recommended, with an appropriate diet and tranquilizers.

But Dr. Falchuk did not do what he was expected to do. Instead, he began to question, and listen, and observe, and then to think differently about Anne’s case. He thought outside of the box of algorithms, of the clinical decision tree of symptoms and laboratory results contained within a box. Groopman admits that algorithms can be useful for run-of-the-mill diagnosis and treatment. But they quickly fall apart when a doctor needs to think outside of the box, when symptoms are vague or multiple and confusing, or when test results are inexact. In such cases – the kind of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they can constrain it.

Groopman points out that a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the canon in many hospitals. Treatment outside the statistically proven are considered taboo until a sufficient body of data can be generated from clinical trials. Of course, Dr. Groopman opines that every doctor should consider research studies in choosing a therapy. But today’s rigid reliance on evidence-based medicine risks having the doctor choose care passively, solely by the numbers. Statistics cannot substitute for the human being before you; statistics embody averages, not individuals.

In Anne Dodge’s case, after a myriad of tests and procedures, it was her words that led Dr. Falchuk to correctly diagnose her illness and save her life. Despite a dazzling array of technologies, language is still the bedrock of clinical practice. We tell the doctor what is bothering us, what we feel is different, and then respond to his questions. This dialogue is our first clue to how our doctor thinks. And so, this is how this book begins, exploring what we learn about a physician’s mind from what he says and how he says it. But it is not only clinical logic that patients can extract from their dialogue with a doctor. They can also gauge his emotional temperature. Although typically it is the doctor who assesses our emotional state, few of us realize how strongly a physician’s mood and temperament influence his medical judgment.

This book follows the path that we take when we move through today’s medical system. If we have an urgent problem, we rush to the emergency room. There, doctors often do not have the benefit of knowing us, and must work with limited information about our medical history. Jerome Groopman examined how doctors think under these conditions, how keen judgments and serious cognitive errors are made under the time pressures of the ER.

If our clinical problem is not an emergency, then our path begins with our primary care physician—if a child, a pediatrician; if an adult, an internist. In today’s parlance, these primary care physicians are termed “gatekeepers,” because they open the portals to specialists. The narrative continues through these portals; at each step along the way, we see how essential it is for even the most astute doctor to doubt his thinking, to repeatedly factor into his analysis the possibility that he is wrong. We also encounter the tension between his acknowledging uncertainty and the need to take a clinical leap and act.

In this book, Jerome Groopman pinpoints the forces and thought processes behind the decisions doctors make. Groopman explores why doctors err and shows when and how they can avoid snap judgments, embrace uncertainty, communicate effectively, and employ other skills that can profoundly impact our health. This book describes in detail the warning signs of erroneous medical thinking and reveals how new technologies may actually hinder accurate diagnoses. How Doctors Think offers direct, intelligent questions patients can ask their doctors to help them get back on track.

Groopman got the idea for this book while on attending rounds on “General Medicine,” with a group of interns, residents and medical students. He conducted the rounds in the traditional manner. One member of the team first presents the salient aspects of the case and then the group moves to the bedside, where they talk to the patient and examine him. On returning to the conference room, Groopman uses the Socratic Method in the discussion encouraging the students and residents to challenge each other and to challenge Groopman with their ideas. However, on that September morning, Groopman realized something was profoundly wrong with the way they were learning to solve clinical puzzles and care for people.

You hear this kind of criticism – that each new generation of young doctors is not as insightful or competent as its forebears regularly among older physicians, often couched like this: “When I was in training thirty years ago, there was real rigor and we had to know our stuff. Nowadays, well. . .” These wistful, aging doctors speak as if some magic that had transformed them into consummate clinicians has disappeared. I suspect each older generation carries with it the notion that its time and place, seen through the distorting lens of nostalgia, were superior to those of today. Dr. Groopman admits to his own similar nostalgia, which on reflection revealed major flaws in his own medical training. The nature of the deficiency, the type of flaw, is what separates each generation of young trainees.

Groopman continues with the approach that Dr. Falchuk used as he guided Mrs. Dodge into his office and to the chair in front of his desk. She looked at the six-inch stack of papers on his desk. It was the dossier she had seen on the desk of her endocrinologist, hematologist, infectious disease physician, psychiatrist and nutritionist for the past fifteen years. It was getting larger with each visit. But then Dr. Falchuk did something that caught Anne Dodge’s eye: he moved those records to the far side of his desk, withdrew a pen from his white coat, and took a clean tablet of line paper from his drawer and began. “Before we talk about why you are here today, let’s go back to the beginning. Tell me about when you first didn’t feel good.”

Anne looked confused. Hadn’t the doctor spoken with her internist and looked at her records? “I have bulimia and anorexia nervosa,” she said softly. Her clasped hands tightened. “And now I have irritable bowel syndrome.” Falchuk smiled. “I want to hear your story, in your own words.” As Ann looked at the clock, she detected no hint of rush or impatience in the doctor. It seemed as though he had all the time in the world. As she seemed exasperated to tell the long and tortuous story, she was encouraged by the short phrases: “Uh-huh,” “I’m with you,” “Go on.” As Anne became confused in her own story, Falchuk continued his encouragement with, “Don’t worry about exactly when. . . I can check that later in the records. Let’s talk about the past months. . . Now tell me what happens after each meal.”

After he took her into the exam room and they returned to the desk, Anne’s energy was waning. Falchuk said, “I’m not at all sure this is irritable bowel syndrome or that your weight loss is only due to bulimia and anorexia nervosa.” Anne felt more confused and fought off the urge to cry. She was about to refuse the bowel biopsy, just as Falchuk repeated emphatically that something else might account for her condition. “Given how poorly you are doing, how much weight you’ve lost, what’s happened to your blood, your bones and your immune system over the years, we need to be absolutely certain of everything that’s wrong.”

When Groopman met with Anne Dodge one month after her appointment with Dr. Falchuk, she said that he’d given her the greatest Christmas present ever. She had gained nearly twelve pounds. The intense nausea, the urge to vomit, the cramps and diarrhea that followed breakfast, lunch and dinner as she struggled to fill her stomach with cereal, bread and pasta had all abated. The tests and endoscopy showed that she had celiac disease or sprue. She had an autoimmune disorder, in essence an allergy to gluten, a primary component of many grains—the very thing her nutritionist was having her force down.

The rest of the Anne Dodge story is very heartwarming, as are the other nine cases. In all of them, there is a misdiagnosis. All are illustrative of errors in communication that caused the unnecessary suffering. In one chapter, Groopman, reports on his own case; he sought help from six renowned hand surgeons for an incapacitating problem and got four different opinions. [Actually he is lucky. I know of a case where eight doctors rendered nine opinions. One doctor’s second opinion was quite different from his first opinion.]

Groopman touches on many of the challenges of our day, especially the push to see more patients faster because of cost controls, managed care and the implementation of short cuts in algorithms. This can best be managed by frank discussions between doctor and patient. This book has been written with the patient in mind as a reader also. We should recommend it to our patients in addition to our colleagues. We would all benefit from applying an understanding of “how doctors think.”

The audio book read by Michael Prichard does a commendable interpretation of the demeanor of a trustworthy clinician, which is the primary purpose of the book. Although Prichard has done numerous audio book recordings, this one is rather straightforward, with few characters, and thus doesn’t test his repertoire, but does lend a depth to the message whether before or after the book read.